TOWARD A HEALTHY FUTURE WORKING TOGETHER TO END NEGLECTED TROPICAL DISEASES AND MALNUTRITION OCTOBER 2014 SABIN VAccINE INstITUTE The Sabin Vaccine Institute’s mission is to reduce needless human suffering from vaccine-preventable and neglected tropical diseases by developing new vaccines, advocating for increased use of existing vaccines, and promoting expanded access to affordable medical treatments. THE GLOBAL NETWORK FOR NEGLecteD TROPICAL DISEASES The Global Network for Neglected Tropical Diseases is an advocacy initiative of the Sabin Vaccine Institute that works in partnership with international agencies, governments, academic institutions, corporations, non-governmental development organizations and the general public to raise the awareness, political will and funding necessary to control and eliminate the seven most common neglected tropical diseases (NTDs) by 2020. “Toward a Healthy Future” is endorsed by: TOWARD A HEALTHY FUTURE: WORKING TOGETHER to END NEGlected TROPICAL DISEASES AND MALNUTRITION POLICY BRIEF Executive Summary 6 Introduction 9 The Impact of NTDs on Nutrition 10 A High-Impact Intervention: Deworming for Better Health and Nutrition 12 Opportunities for Action 15 Linking Policy for Scale and Impact 19 Call to Action: The Path Toward a Healthy Future 22 POLICY BRIEF Toward a Healthy Future Executive Summary All of the 34 countries carrying the highest levels of malnutrition are endemic for neglected tropical diseases (NTDs). In fact, ten of these countries make up 90 percent of the global NTD burden. Not only do several of these diseases hinder childhood growth and development, but they also cause, aggravate and intensify the loss of key nutrients, especially Vitamin A and iron, and result in adverse pregnancy outcomes. The international development community has the opportunity to act now to focus new energy toward eliminating the policy, program and resource gaps that hinder existing efforts to meet global goals to end both NTDs and malnutrition. Simply put, • All of the countries with NTDs stand in the way of improved health and nutrition, making it essential for the highest levels of the development community to embrace a coordinated, integrated response malnutrition are also endemic for neglected to address both problems. Given the strong momentum behind the fight to tropical diseases end NTDs and the growing unified movement to end malnutrition, now is a • Malnutrition causes and propitious time to identify synergies in policies, leverage delivery platforms is aggravated by NTDs and foster greater collaboration across sectors to deliver high-impact health • Integrated policies and and nutrition solutions to those still locked in poverty. advocacy are crucial to improving outcomes This brief explores the relationship between, and opportunity to address, for both two types of NTDs — intestinal worm infections and schistosomiasis — and malnutrition. It makes the case for international development partners to scale up deworming treatments alongside efforts to improve nutrition and other determinants of health as a way to reach more people in need and ensure lasting impact. In this brief, we call on international policymakers and development partners to: 9 Recognize the joint impact of NTDs and malnutrition and the benefits of addressing them in tandem. 9 Expand access to routine deworming treatments for all populations at risk. 6 of 26 Executive Summary 9 Include deworming in strategies that aim to improve health and nutrition outcomes for mothers and children. 9 Increase resources and link policies that facilitate joint programming and partnerships, and encourage endemic countries to prioritize NTDs and malnutrition in their domestic policies. 9 Ensure lasting success by simultaneously investing in water, sanitation and hygiene (WASH) and other social determinants of health 9 Mobilize greater political and financial support for tackling NTDs and malnutrition during international and regional fora. Like the nutrition movement, the NTD community is a diverse group of advocates, health experts, policymakers, industry partners and donors. Interventions that advance the 2020 NTD control and elimination targets set by the World Health Organization — including deworming for intestinal worm infections and schistosomiasis — will reduce malnutrition in children and expectant mothers. While some joint initiatives are underway and have demonstrated success, ample opportunities remain for policymakers, partners and global health and development organizations to identify opportunities to coordinate policies, programs and resources to eliminate the remaining gaps between health and nutrition. Capitalizing on the combined resources of the NTD and nutrition communities will advance global development goals, but integrated approaches with other groups, including those in the WASH sector, will also be needed to accelerate and sustain progress towards reducing poverty and inequality. See page 22 for the Call to Action. 7 of 26 Introduction Introduction Efforts to end neglected tropical diseases (NTDs) and malnutrition should be tackled through integrated programs and policies as a way to reach more people in need and advance global health and development goals.1 Today, more than 1.4 billion people living in Africa, the Americas and Asia are affected by at least one of the 17 NTDs listed by the World Health Organization (WHO).2 These infections can cause impaired childhood growth and development, poor pregnancy outcomes, blindness and crippling physical disfigurements, and they increase the likelihood of contracting HIV, thwarting opportunities for social progress and economic growth. NTDs persist in communities that do not have access to clean water, proper sanitation and adequate healthcare. And, they overlap geographically with populations who are at the greatest risk for malnutrition. It is no coincidence that all 34 countries carrying the highest levels of malnutrition are endemic for NTDs. These nations not only display alarming levels of malnutrition and are home to 90 percent of the world’s stunted children, but ten of them account for 90 percent of the global NTD burden. A prime example of this overlap exists in India, which has more people suffering from NTDs than in any other country in the world as well as the highest number of stunted and wasted children under the age of five.3, 4, 5 10 of the 34 countries with the highest levels of malnutrition account for 90% of the world’s NTD burden. Afghanistan Guatemala Nigeria Angola Kenya Pakistan Bangladesh India Philippines Burkina Faso Indonesia Rwanda Cameroon Iraq South Africa Côte d’Ivoire Madagascar Sudan Chad Malawi Tanzania Democratic Mali Uganda Republic of Mozambique Vietnam Congo Egypt Myanmar Yemen Nepal Zambia Ethiopia Ghana Niger 9 of 26 POLICY BRIEF Toward a Healthy Future The Impact of NTDs on Nutrition Approximately 805 million people worldwide suffer from undernutrition — a consequence of poor nutrient intake due to lack of food or the body’s inability to absorb nutrients.6 There is a growing body of evidence showing that poor nutrient intake may increase susceptibility to parasitic diseases and together, this combination exacerbates stunting (chronic malnutrition), wasting (acute malnutrition) and the loss of nutrients. Additionally, concurrent parasitic infections have detrimental effects on health and development, further fueling a destructive cycle of malnutrition and infection.7 Two types of NTDs cause and perpetuate malnutrition: intestinal worm infections — also known as soil-transmitted helminths (STH) — and schistosomiasis, a waterborne parasitic disease. These diseases contribute to stunting and wasting as well as the loss of Vitamin A and iron — two of the three most detrimental micronutrient deficiencies that represent a major threat for maternal, newborn and child health. A Diminished Future: Delayed Childhood Growth and Development Intestinal worms — specifically hookworm, whipworm and roundworm — and schistosomiasis are among the underlying causes of stunting. 8, 9, 10 A study in Peru demonstrated that 7–14 months-old children burdened by intestinal worms were 84 percent more likely to be stunted. Infections appeared in children as young as 8 months of age, a time when infants start to become more active and mobile.11 Infants and young children are often exposed to NTD-contaminated soil and water during everyday activities like eating, playing and bathing, highlighting the importance of improving water, sanitation and hygiene (WASH) alongside treatment efforts. Another study revealed substantially greater odds of stunting, wasting and anemia among Kenyan children (between the ages of 5 and 18) who were often coinfected with a combination of schistosomiasis, hookworm, or malaria.12 Children suffering from these infections face significant growth deficits, cognitive delays and impaired learning ability. For instance, it has been shown that children infected with whipworm are approximately 4.5 times more likely to perform poorly in tests of verbal fluency.13 10 of 26 The Impact of NTDs on Nutrition TWO TYPES OF NTDS THAT CAUSE AND PERPETUATE MALNUTRITION: Intestinal worm infections Schistosomiasis WHAT MAKES THEM SO HARMFUL: They lead to stunting and wasting, as well as the loss of Vitamin A and iron — two of the three most detrimental micronutrient deficiencies that represent a major threat for maternal, newborn and child health. A Competition for Nutrients: Vitamin A Roundworm, one of the most prevalent intestinal worm infections,